Abstract
Fractures of the proximal metaphysis and of the proximal third of the tibia shaft represent a minority of tibia fractures. Intramedullary nailing is discussed controversially because of the risk of malalignment. Nevertheless, the biomechanical and biological advantages of intramedullary nailing are also valid for fractures of the proximal tibia. The fracture needs reduction before the nailing procedure is started. Reduction is done with the help of pointed reduction forceps, Schanz’ screws, cerclage wires, and secured with lag screws, K-wires or a small plate. The choice of the correct entry portal is of utmost importance for good alignment. The safe zone for tibia nail insertion is located in front of the lateral tibial spine. The recently described suprapatellar entry portal is a promising alternative to the conventional infrapatellar approach. Slight reaming, the use of a guide wire and a cannulated nail are recommended. Poller screws may help to guide the nail into its correct position. The proximal fragment should be fixed with three interlocking screws in different directions. Outcome is excellent if the procedure has been performed successfully and stable fixation obtained.
Access this chapter
Tax calculation will be finalised at checkout
Purchases are for personal use only
References
Court-Brown CM, McBirnie J. The epidemiology of tibial fractures. J Bone Joint Surg Br. 1995;77:417–21.
Tytherleigh-Strong GM, Keating JF, Court-Brown CM. Extra-articular fractures of the proximal tibial diaphysis: their epidemiology, management and outcome. J R Coll Surg Edinb. 1997;42(5):334–8.
Tice JW. Extra-articular fractures of the proximal tibial diaphysis: their epidemiology, management and outcome. J R Coll Surg Edinb. 1998;43(6):428–9. Comment.
Vidyadhara S, Sharath KR. Prospective study of the clinico-radiological outcome of interlocked nailing in proximal third tibial shaft fractures. Injury. 2006;37:536–42.
Attal R, Hansen M, Kirjavainen M, Bail H, Hammer TO, Rosenberger R, Höntzsch D, Rommens PM. A multicentre case series of tibia fractures treated with the Expert Tibia Nail (ETN). Arch Orthop Trauma Surg. 2012;132:975–84.
Oestern HJ, Tscherne H. Pathophysiology and classification of soft tissue injuries associated with fractures. In: Tscherne H, Gotzen L, editors. Fractures with soft tissue injuries. Berlin: Springer; 1984. p. 1–8.
McKellop HA, Sigholm G, Redfern FC, Doyle B, Sarmiento A, Luck Sr JV. The effect of simulated fracture-angulations of the tibia on cartilage pressures in the knee joint. J Bone Joint Surg Am. 1991;73:1382–91.
Rios-Luna A, Fahandezh-Saddi H, Villanueva-Martínez M, López AG. Pearls and tips in coverage of the tibia after a high energy trauma. Indian J Orthop. 2008;42:387–94.
Peindl RD, Zura RD, Vincent A, Coley ER, Bosse MJ, Sims SH. Unstable proximal extraarticular tibia fractures: a biomechanical evaluation of four methods of fixation. J Orthop Trauma. 2004;18:540–5.
Blokker CP, Rorabeck CH, Bourne RB. Tibial plateau fractures. An analysis of the results of treatment in 60 patients. Clin Orthop. 1984;182:193–9.
Oh JK, Oh CW, Jeon IH, et al. Percutaneous plate stabilization of proximal tibial fractures. J Trauma. 2005;59:431–7.
Oh CW, Oh JK, Kyung HS, et al. Double plating of unstable proximal tibial fractures using minimally invasive percutaneous osteosynthesis technique. Acta Orthop. 2006;77:524–30.
Stannard JP, Finkemeier CG, Lee J, Kregor PJ. Utilization of the less-invasive stabilization system internal fixator for open fractures of the proximal tibia: a multi-center evaluation. Indian J Orthop. 2008;42:426–30.
Ma CH, Wu CH, Yu SW, Yen CY, Tu YK. Staged external and internal less-invasive stabilisation system plating for open proximal tibial fractures. Injury. 2010;41:190–6.
Bonnevialle P, Fouque E, Cariven P, Bertin R, Asencio G, Mansat M. Value of external fixation in proximal tibial fractures. Rev Chir Orthop Reparatrice Appar Mot. 1997;83(7):602–12 [Article in French].
Bolhofner BR. Indirect reduction and composite fixation of extraarticular proximal tibial fractures. Clin Orthop Relat Res. 1995;315:75–83.
Lang GJ, Cohen BE, Bosse MJ, Kellam JF. Proximal third tibial shaft fractures. Should they be nailed? Clin Orthop Relat Res. 1995;315:64–74.
Hansen M, Mehler D, Voltmer W, Rommens PM. The extraarticular proximal tibial fracture. Unfallchirurg. 2002;105:858–72. Review. [Article in German].
Bhandari M, Audige L, Ellis T, Hanson B, Evidence-Based Orthopaedic Trauma Working Group. Operative treatment of extra-articular proximal tibial fractures. J Orthop Trauma. 2003;17:591–5. Review.
Konrad G, Südkamp N. Extra-articular proximal tibial fracture. Chirurg. 2007;78:161–71; quiz 172–3. [Article in German].
Ahlers J, von Issendorff WD. Incidence and causes of malalignment following tibial intramedullary nailing. Unfallchirurgie. 1992;18(1):31–6. [Article in German].
Freedman EL, Johnson EE. Radiographic analysis of tibial fracture malalignment following intramedullary nailing. Clin Orthop Relat Res. 1995;315:25–33.
McKee MD, Schemitsch EH, Waddell JP, Yoo D. A prospective, randomized clinical trial comparing tibial nailing using fracture-table traction versus manual traction. J Orthop Trauma. 1999;13(7):463–9.
Reynders P. Technical notes on a radiolucent distractor for indirect reduction and intramedullary nailing. J Orthop Trauma. 1998;12(3):219–20. Letter to the editor.
Jackson M, Topliss CJ, Atkins RM. Fine wire frame-assisted intramedullary nailing of the tibia. J Orthop Trauma. 2003;17(3):222–4.
Rommens PM, El Attal R, Hansen M, Kuhn S. Intramedullary nailing of proximal tibia fractures. Oper Orthop Traumatol. 2011;23(5):411–22. [Article in German].
Habernek H. Percutaneous cerclage wiring and interlocking nailing for treatment of torsional fractures of the tibia. Clin Orthop Relat Res. 1991;267:164–8.
Huang MT, Lin CJ. Percutaneous cerclage wiring-assisted interlocking nailing for torsional tibia fractures: a modification with improved safety and simplicity. J Trauma. 2011;71(4):1054–8.
Archdeacon MT, Wyrick JD. Reduction plating for provisional fracture fixation. J Orthop Trauma. 2006;20(3):206–11.
McConnell T, Tornetta 3rd P, Tilzey J, Casey D. Tibial portal placement: the radiographic correlate of the anatomic safe zone. J Orthop Trauma. 2001;15(3):207–9.
Hernigou P, Cohen D. Proximal entry for intramedullary nailing of the tibia. The risk of unrecognised articular damage. J Bone Joint Surg Br. 2000;82(1):33–41.
Walker RM, Zdero R, McKee MD, Waddell JP, Schemitsch EH. Ideal tibial intramedullary insertion point varies with tibial rotation. J Orthop Trauma. 2011;25(12):726–30.
Lembcke O, Ruter A, Beck A. The nail-insertion point in unreamed tibial nailing and its influence on the axial malalignment in proximal tibial fractures. Arch Orthop Trauma Surg. 2001;121(4):197–200.
Althausen PL, Neimann R, Finkemeier CG, Olson SA. Incision placement for intramedullary tibia nailing: an anatomic study. J Orthop Trauma. 2002;16(10):687–90.
Hansen M, Mehler D, Hessmann MH, Blum J, Rommens PM. Intramedullary stabilization of extraarticular proximal tibial fractures: a biomechanical comparison of intramedullary and extramedullary implants including a new proximal tibia nail (PTN). J Orthop Trauma. 2007;21(10):701–9.
Thelen S, Betsch M, Grassmann JP, Spoor V, Eichler C, Koebke J, Windolf J, Hakimi M, Wild M. Angle stable locking nails versus conventionally locked intramedullary nails in proximal tibial shaft fractures: a biomechanical study. Arch Orthop Trauma Surg. 2012;132(1):57–63.
Hansen M, Blum J, Mehler D, Hessmann MH, Rommens PM. Double or triple interlocking when nailing proximal tibial fractures? A biomechanical investigation. Arch Orthop Trauma Surg. 2009;129(12):1715–9.
Drosos GI, Stavropoulos NI, Kazakos KI. Peroneal nerve damage by oblique proximal locking screw in tibial fracture nailing: a new emerging complication? Arch Orthop Trauma Surg. 2007;127(6):449–51.
Hansen M, Roux P, Adolph J, Blum J. Risk of iatrogenic neurovascular damage by proximal 3-dimensional intramedullary nailing of the tibia. Unfallchirurg. 2010;113(6):476–80 [Article in German].
Tornetta 3rd P, Collins E. Semiextended position of intramedullary nailing of the proximal tibia. Clin Orthop Relat Res. 1996;328:185–9.
Kubiak EN, Widmer BJ, Horwitz DS. Extra-articular technique for semiextended tibial nailing. J Orthop Trauma. 2010;24(11):704–8.
Gelbke MK, Coombs D, Powell S, DiPasquale TG. Suprapatellar versus infra-patellar intramedullary nail insertion of the tibia: a cadaveric model for comparison of patellofemoral contact pressures and forces. J Orthop Trauma. 2010;24(11):665–71.
Jakma T, Reynders-Frederix P, Rajmohan R. Insertion of intramedullary nails from the suprapatellar pouch for proximal tibial shaft fractures. A technical note. Acta Orthop Belg. 2011;77(6):834–7.
Eastman J, Tseng S, Lo E, Li CS, Yoo B, Lee M. Retropatellar technique for intramedullary nailing of proximal tibia fractures: a cadaveric assessment. J Orthop Trauma. 2010;24(11):672–6.
Liporace FA, Stadler CM, Yoon RS. Problems tricks, and pearls in intramedullary nailing of proximal third tibial fractures. J Orthop Trauma. 2013;27(1):56–62.
Krettek C, Stephan C, Schandelmaier P, Richter M, Pape HC, Miclau T. The use of Poller screws as blocking screws in stabilising tibial fractures treated with small diameter intramedullary nails. J Bone Joint Surg Br. 1999;81(6):963–8.
Ricci WM, O‘Boyle M, Borrelli J, Bellabarba C, Sanders R. Fractures of the proximal third of the tibial shaft treated with intramedullary nails and blocking screws. J Orthop Trauma. 2001;15(4):264–70.
Stedtfeld HW, Mittlmeier T, Landgraf P, Ewert A. The logic and clinical applications of blocking screws. J Bone Joint Surg Am. 2004;86-A Suppl 2:17–25.
Shahulhameed A, Roberts CS, Ojike NI. Technique for precise placement of poller screws with intramedullary nailing of metaphyseal fractures of the femur and the tibia. Injury. 2011;42(2):136–9. doi:10.1016/j.injury.2010.04.013.
Kuhn S, Hansen M, Rommens PM. Extending the indications of intramedullary nailing with the Expert Tibial Nail. Acta Chir Orthop Traumatol Cech. 2008;75(2):77–87.
Lindvall E, Sanders R, Dipasquale T, Herscovici D, Haidukewych G, Sagi C. Intramedullary nailing versus percutaneous locked plating of extra-articular proximal tibial fractures: comparison of 56 cases. J Orthop Trauma. 2009;23(7):485–92. doi:10.1097/BOT.0b013e3181b013d2.
Hiesterman TG, Shafiq BX, Cole PA. Intramedullary nailing of extra-articular proximal tibia fractures. J Am Acad Orthop Surg. 2011;19(11):690–700.
Wysocki RW, Kapotas JS, Virkus WW. Intramedullary nailing of proximal and distal one-third tibial shaft fractures with intraoperative two-pin external fixation. J Trauma. 2009;66(4):1135–9. doi:10.1097/TA.0b013e3181724754.
Nork SE, Barei DP, Schildhauer TA, Agel J, Holt SK, Schrick JL, Sangeorzan BJ. Intramedullary nailing of proximal quarter tibial fractures. J Orthop Trauma. 2006;20(8):523–8.
Author information
Authors and Affiliations
Corresponding author
Editor information
Editors and Affiliations
Rights and permissions
Copyright information
© 2015 Springer-Verlag London
About this chapter
Cite this chapter
Rommens, P.M., Hessmann, M.H. (2015). Proximal Tibia. In: Rommens, P., Hessmann, M. (eds) Intramedullary Nailing. Springer, London. https://doi.org/10.1007/978-1-4471-6612-2_21
Download citation
DOI: https://doi.org/10.1007/978-1-4471-6612-2_21
Published:
Publisher Name: Springer, London
Print ISBN: 978-1-4471-6611-5
Online ISBN: 978-1-4471-6612-2
eBook Packages: MedicineMedicine (R0)